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CI`ULI Y 1. L) <br /> a 2 7 2015 <br /> SAN JOAQUIN COUNTY ENVIRONMENT*- VW ORIGINAL <br /> SERVICE REQUEST` FILE wPY <br /> Type of Business or Property FACILITY ID 9 SOMMQUESTO <br /> 'FPS J'7t9 7j Q Y) JL `-3�13t?ob-7D-C)`7� <br /> OWNER I OPERATOR <br /> e fi bl� ) Y9 CHECKif)31LLINC Ann e$S� <br /> FACftM NAME Q �j J-f1 e <br /> SfrE ADDRESS 7;�'e¢ f ! <br /> on 7c cf J'-�atrf- 1 '1- <br /> 3traetNu Dr 1et Nam CI Zi Cnd <br /> NOME OCNiIUUNGADDRESS (If Differentfrom Site Address) <br /> a L) <br /> Strout u Y Slra¢t N <br /> CITYS )vC JJ_fal�1 STATE ZlP y !� <br /> (HONE#1 APN# LAND USE APPUCAMN# G� <br /> pHDNE$2 aT• 1305 DISTRICT L=TtoN COOS <br /> CONTRACTOR I SF VICE REE QUESTOR <br /> REaUESTOl2 .Y n CHfiCK K Er�LING ADDRE33 LJ <br /> BUSINESS NAME UV1 IVY NONE# Exr. <br /> HOME or MA1LFNaAIDD13E.as�0� /'1 � � FAx# <br /> clrr C. /-�11 <br /> C4 STATE ZIP <br /> MLLING ACKNQYVLEDG5KF-NT:1, the undersigned propefty or hu-siness owner, operator or euthorizecl agentof same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accoi-dance with all S,ar4 JoAQUCN <br /> CouKrY OrdInanae Codes,Standards, TE and 5eDERAL laws_ <br /> DATE' <br /> APPI-ICANT'S SIGNATURE: � 14� � <br /> ) <br /> QRDPERTYIlauslNEssOWNER ERArOK ANADER OTHERAuTHoR¢EDAGENT Q <br /> If APPLicAN7 is not the BiLu roo of du`JTorizatlon to sign is required Ttrta <br /> AUTHORIZ4TION TO RELEASE INFORMATION: When applicable, I.the Owner or operator of the property located at the above <br /> site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment Information <br /> to the$AN JoAou1N Counm ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is provided to me or <br /> my representative. <br /> TYPE OF SERvICE REQUESTED: r - <br /> COMMENTS: - <br /> o �. <br /> SAN JOAQUiN COUNTY <br /> r ENVlROMENTAL. <br /> HEALTH DEPAR-mr= -( <br /> ACCEPTED BY; EMPLOYEE#: DATE: <br /> ASSIGNED TO: r7r EMPLOYEE#: DATE: <br /> Pate'service Compiated (it already completed): SERVICE CODE: et� P <br /> Fee Amount -- Amount Paid C7 C7 v f J Payment pate 1 G <br /> Payment Type ( [� <br /> Invoice# Check# RecetYed 13y <br /> ',��v tJ <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />